Provider Demographics
NPI:1407248222
Name:PEBBLE CREEK COUNSELING CENTER
Entity Type:Organization
Organization Name:PEBBLE CREEK COUNSELING CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:MICHELLE
Authorized Official - Middle Name:
Authorized Official - Last Name:MAIN
Authorized Official - Suffix:
Authorized Official - Credentials:ACMHC
Authorized Official - Phone:435-249-0321
Mailing Address - Street 1:494 E 2400 N STE B
Mailing Address - Street 2:
Mailing Address - City:TOOELE
Mailing Address - State:UT
Mailing Address - Zip Code:84074
Mailing Address - Country:US
Mailing Address - Phone:435-249-0321
Mailing Address - Fax:435-249-0360
Practice Address - Street 1:494 E 2400 N STE B
Practice Address - Street 2:
Practice Address - City:TOOELE
Practice Address - State:UT
Practice Address - Zip Code:84074
Practice Address - Country:US
Practice Address - Phone:435-249-0321
Practice Address - Fax:435-249-0360
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-03-03
Last Update Date:2015-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT327705-6009101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty